Corneal refractive surgery in children still in beginning stages

Issue: July 10, 2009

ByRichard L. Lindstrom, MD

Richard L. Lindstrom

While I have implanted IOLs in children as young as 3 years, I have never performed corneal refractive surgery on a patient under the age of 18 years.

One might appropriately ask, “Why not,” for I am asked to perform LASIK or PRK every week in my practice by desperately motivated parents and their children. After all, what is the difference in handicap between +12 D of anisometropia and –12 D of anisometropia?

While a member of the University of Minnesota Department of Ophthalmology faculty in the 1980s, I did my first IOL implants in children. Working with a superb group of pediatric ophthalmologists, all unilateral pediatric cataracts were operated and initially fit with aphakic contact lenses. Most did well until the age of 3 to 4 years, but then many kids simply became unmanageable and contact lens intolerant, even with dedicated parents and doctors. Our indication for a secondary posterior chamber lens implant was a child who was being successfully managed with a contact lens and was compliant with amblyopia therapy, but subsequently became contact lens intolerant. We had significant success with this approach, and over the next 25 years, most ophthalmologists charged with the care of these patients have become confident enough in the outcomes to recommend primary implantation of a posterior chamber IOL at the time of cataract surgery in many young children in the amblyopic age group.

While controversy remains, IOL implantation in the child over the age of 2 years has become common practice, and most pediatric ophthalmologists are well-trained and expert in this approach.

I believe corneal refractive surgery for the anisometropic child with secondary amblyopia is currently at the same stage of development as IOL implants in children in the early 1980s. I fully support clinical trials treating the child with anisometropic amblyopia if the child is compliant with amblyopia therapy and a motivated family and a pediatric ophthalmologist with expertise in amblyopia therapy are involved. In some children who will just not wear a patch, penalization with atropine drops may be an alternative.

In my opinion, those who can successfully wear a contact lens should be encouraged for now to continue to do so, but corneal refractive surgery is a reasonable option for those who cannot or will not wear a contact lens. By treating this group of patients, we will learn much about the best surgical approach — PRK, PRK with mitomycin C or LASIK — the incidence and severity of complications, and the efficacy in achieving a meaningful improvement in visual acuity and, more important, visual function and quality of life. I suspect that as knowledge grows, in a decade or two, we will learn which children can be expected to benefit the most from corneal refractive surgery and at what stage we should resort to this therapy.

For now, I personally do not operate on children, and I discourage most patients from undergoing corneal refractive surgery until their refractive error stabilizes, which is usually in their early to mid 20s. The primary procedure, whether it be PRK or LASIK, carries the best risk-to-benefit ratio, and my goal is to reduce to a minimum the number of patients who require more than one surgical treatment.

One final observation on the positive side is that I have treated many adults with anisometropic amblyopia, and both they and I continue to be impressed that many show significant improvement in both best corrected and uncorrected visual acuity, visual function and subjective quality of life. This experience in adult patients makes me optimistic that we will find a class of children who will benefit greatly from corneal refractive surgery.

However, for now, I remain convinced that corneal refractive surgery in the child is best performed inside a carefully planned clinical trial with institutional review board approval and all the patient — and surgeon — safeguards that approach entails. I applaud those who are participating in these clinical trials and look forward to learning more from their pioneering work.